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Officials: Medevac crews hesitant since crash

Reliance on helicopters, 'golden hour' questioned by panel

By Robert Little

November 25, 2008

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State emergency medical officials said yesterday that some ambulance crews in Maryland are "skittish" since a fatal medevac helicopter crash in September and might be too reluctant to transport accident victims to the hospital by air.

The concern was raised as members of an expert panel exploring the state's emergency medical system said they will take a critical look at the state's heavy reliance on helicopter transport. One even challenged the "golden hour" dictum born in Maryland that says patients should reach a hospital within an hour of injury.

Convened in response to the Sept. 28 crash in Prince George's County that killed four people, the seven-member panel plans to issue a report today on whether Maryland makes appropriate use of transport helicopters. Two patients involved in the crash were flown based on the condition of their wrecked vehicle, rather than apparent injuries, sparking a review of state medevac guidelines.

After hearing presentations from emergency medical officials yesterday, panel members were largely complimentary of Maryland's emergency medical system, calling it a national model.

Dr. Robert C. MacKersie, a San Francisco surgeon, said he hopes the group's work can spark a broader discussion leading to national triage guidelines.

But some members expressed skepticism about a heavy reliance on helicopters to transport accident victims to the hospital, a practice whose value has proved difficult to verify through study. One panel member, Vanderbilt University trauma surgeon John A. Morris Jr., questioned whether Maryland puts too much emphasis on getting patients to a trauma center as quickly as possible, a concept that has also never been validated by scientific evidence.

"I know that time is easy to quantify, and I know that I am in the home of the golden hour," Morris said, referring to the phrase coined by Shock Trauma founder R Adams Cowley. "However, I think it is naive to think in 2008 that the value of helicopter transport is time-based. The value of helicopter transport nationally is quality-of-care based."

One member of the panel, Nevada physician Bryan Bledsoe, has published studies raising doubts about whether helicopters get patients to a hospital faster and save more lives than ground ambulances.

Bledsoe and Morris said they were surprised to learn that Maryland's medevac flights carry one paramedic, while typical flights in other states include two health professionals.

The helicopter crash - and a recording of a dispatcher telling the pilot that Charles County ambulance drivers at the scene "never want to drive to the hospital" - has fueled a national debate over the appropriate use of helicopters for trauma patients.

The Maryland Institute for Emergency Medical Services Systems has already made one change in the state's triage process in response to the crash, telling ambulance crews to consult with a hospital before calling a helicopter for patients without obvious injuries. Previously ambulance crews could call for a helicopter themselves, based on written protocols designed to predict the presence of injuries that are not apparent.

State officials seemed to question yesterday whether that change has gone too far. Dr. Robert Bass, director of the system, said 226 patients have been flown to the state's trauma hospitals since the accident, a pace of about 1,680 a year. Last year the state flew more than 4,100 patients.

"I'm concerned right now that there are some patients that should be flown to trauma centers that are not," said Dr. Douglas J. Floccare, aeromedical director of the state emergency medical system. "There's some skittishness out there."

Dr. Thomas M. Scalea, physician-in-chief at Shock Trauma, said he thought Maryland's emergency medical system has beeen "under attack" since the crash, and told the group that "it's essential that we preserve it."

Two hours after the panel adjourned for private deliberations, Scalea joined other officials at Shock Trauma for a news conference with patient Jordan Wells, 18, who survived the helicopter crash.

Speaking publicly for the first time, Wells said she was thrown from the aircraft as it crashed and awoke in the woods nearby. She said she could not recall details that would offer clues about the cause.

"I just realized something was wrong when we started hitting branches," said Wells, who had part of her leg amputated after the crash.

Members said the report to be issued at 11 a.m. today will focus on how medics select victims for transport, not on matters of flight safety, maintenance or other issues related to the crash.